CHIEF COMPLAINT. Patient history
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- Duane Lyons
- 6 years ago
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1 Patient Name: Appointment date: Address: Referred by: (Doctor s name and phone #) CHIEF COMPLAINT Which shoulder is painful? Right Left Both shoulders equal Right more painful than Left Left more painful than Right Patient history Height: Weight: Are you? Right handed Left handed Use both hands equally What kind of work do you do? How long have you had your shoulder problem? # days # weeks #months #years How did it begin? suddenly gradually What caused your shoulder problem? An accident a period of strenuous activity I don t know A motor vehicle accident after an injury Is your shoulder pain? Getting worse staying about the same getting better How does your shoulder feel? Check all that apply. It hurts It feels weak It feels stiff It feels loose It feels like it slips It catches or locks in certain positions It grinds or pops It aches there is a burning sensation It feels like it is in spasm I have tingling or numbness in my fingers 1
2 Before this shoulder problem started, were you having any problems with your shoulder? yes no Painful Activities I have recently injured my shoulder and have severe pain that prevents me from using it. I have shoulder pain with the following activities. Please check all that apply. using an ATM machine getting a parking ticket reaching in the back seat of the car putting on the seatbelt washing a car turning the steering wheel adjusting car mirror or radio performing gardening/yard work performing housework vacuuming pulling up bed covers sleeping doing the laundry starting a lawnmower putting a belt through the belt loops reaching my wallet fastening a bra Buttoning pants putting on a coat/shirt/sweater combing hair blow drying hair Lifting pushing / pulling Knitting/crochet doing computer work/typing pouring from pitcher getting milk from the refrigerator reaching overhead reaching out to the side carrying heavy objects 2
3 SPORTS Do you have shoulder pain with any of the following sports? Please check all that apply. golf tennis swimming bowling softball baseball hockey racquetball basketball weight lifting volleyball How has your shoulder been treated up to now? I have NOT changed my work to adjust for my shoulder changed my work to adjust for my shoulder stopped working to adjust for my shoulder what kind of work? For my shoulder problem I have already seen my regular doctor a chiropractor an orthopedic surgeon a neurosurgeon a physical therapist a massage therapist Your general health and medications can affect your treatment. Please help us by providing the following information Do you have a Family Physician or Internist?? Yes No Doctor: Date of last visit Date of last complete examination Would you like us to send a copy of our report to the doctor you listed above?? Yes No Another doctor? Address: 3
4 MEDICATION I have not taken any medication for my shoulder condition I was treated with medication Name of medication INJECTIONS THERAPY I have not received an injection for my shoulder condition I have received an injection I have not had any therapy for my shoulder condition I have received therapy for my shoulder condition Date therapy started and duration: SURGERY I have not had any surgery for my shoulder condition I have had any surgery for my shoulder condition Date and type of surgery: Family History: Please provide any pertinent family medical history relating to your parents Illness/condition Father Mother Age at diagnosis Living? If no, date of death Unknown 4
5 Medical problems (Review of Systems) ROS Heart No heart problems Heart attack Blocked arteries in the heart Congestive heart failure Palpitations mumur Cardiomyopathy Pericarditis Cardiomegaly Aortic aneurysm A-fib Conduction disorder Atrial flutter Mitral insufficiency hypertensive heart disease Angina Mitral Valve Prolapse Rheumatic heart disease Cardiac pacemaker ROS Vascular No vascular problems Anemia Hypotension (low blood pressure) Fainting Hypertension (high blood pressure) Phlebitis varicose veins Vasovagal Venous insufficiency ROS Lungs No lung problems Asbestosis asthma bronchitis COPD emphysema PE (pulmonary embolism) pneumonia pneomothorax shortness of breath Sleep apnea ROS Gastrointestinal No GI problems Achalasia anorexia c diff colitis chron s diverticulitis ulcer reflux fecal incontinence gastric bypass gastritis hiatal hernia Irritable bowel syndrome pancreatitis ROS Hepatitis Hepatitis A (year ) Hepatitis B (year ) Hepatitis C (year ) Hepatitis type unknown acute chronic past resolved ROS Genitourinary No GU problems Acute renal failure Chronic renal failure cystitis dialysis kidney stones urinary incontinence 5
6 ROS Neurologic No neurological problems Alzheimers Carpal tunnel syndrome Cerebral Palsy Dementia Diabetic neuropathy Epilepsy ROS Psychological ROS Endocrine No psychological problems Alcoholism Anxiety Bipolar disorder Depression Drug dependence Eating disorder Insomnia Obsessive compulsive disorder Panic attacks Phobias Schizophrenia Paraplegia Parkinson s Peripheral neuropathy Migraines Polio Seizures Stroke TIA s No Endocrine problems Diabetes non insulin dependent Diabetes insulin dependent Graves Addison s Gout Hypothyroidism ROS Infection No infectious disease problems HIV AIDS TB MRSA ROS ENT (Ear, Nose and Throat) ROS Eyes ROS Skin ROS Breast No HEENT problems Dystonia Hearing Aid Hearing Loss Sinusitis Vertigo (positional) No eye problems Blindness Cataracts Glaucoma Macular degeneration Retinopathy No skin problems Cellulitis Eczema Psoriasis Rosacia Shingles No breast problems Benign Mass Cyst Fibrocystic Disease Mastitis Breast Cancer 6
7 Do you have any allergies?? To medicines NO YES Describe: Metal Allergery: NO YES Type of Metal: To iodine x-ray dye shellfish latex Pharmacy Name(and address if known): Pharmacy Phone #: Please list the medications you are currently taking I am not currently taking any medication I am taking the following medication. Medication Dosage times/day Social History The amount you drink and smoke can affect how well bones and ligaments heal and how you react to medicines or anesthesia. Alcohol Tobacco 7 I do not drink I am a social drinker I am a daily drinker Beers / day Glasses of wine / day Liquor drinks / day I do not smoke I smoke packs per day for cigars / week I chew tobacco Beers / week Glasses of wine / week Liquor drinks / week I smoked but stopped year stopped smoking number of years
This information will help us deliver the best possible medical care.
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